CDH Emergency Department Improves Patient Flow

NORTHAMPTON — Prior to a new Mass. Department of Public Health (DPH) ambulance-diversion policy that took affect on Jan. 1, Cooley Dickinson Hospital (CDH) has implemented its own policy to improve patient flow, or the time it takes patients to move through the Emergency Department.

Part of a comprehensive plan at CDH, the new patient-flow policy has been tested and is in place, and emergency department physicians and staff say they are ready for the statewide transition.

A memo from Commissioner of Public Health John Auerbach and Director Paul Dreyer states that, “effective Jan. 1, 2009, ambulance services may honor diversion requests only when a hospital’s emergency department’s status is ‘code black,’ which means that the hospital is closed to all patients due to an internal hospital emergency.”

More than a year ago, Dr. R.F. Conway, medical director of CDH’s 24-bed Emergency Department, anticipated that the DPH would change its regulations governing ambulance diversions. Conway and a team representing nursing, physicians, case management, admitting, transportation, and housekeeping designed the new patient-flow policy that creates a ‘tiered response’ to surges in patients that impacts the ED, as well as the hospital’s clinical units.

“We are committed to meeting the needs of our community,” Conway said. “These changes reflect our desire to work toward continuous improvements and incorporate feedback from our patients.  How we appropriately move patients through our system is a behind-the-scenes activity that patients do not see. They want to receive exceptional, timely care, whether it’s here or at home. We play a vital role in ensuring this level of quality care will continue to be provided at Cooley Dickinson Hospital.”

Conway and Michael Shellenberger, clinical director, said the new policy guides a process for moving patients through the department as well as admitting patients to or discharging them from an inpatient unit, and that teamwork and communication between staff are central to that process.

Conway said overcrowding in the Emergency Department is a complex issue, one that is not related to the number of patients that walk through the emergency department doors at a given time.

Shellenberger added that emergency overcrowding occurs when there are no overnight beds for patients to go to, and then they must remain in the ED for an extended period of time. He noted that key areas of the new patient flow policy include:

• Daily huddles in which charge nurses from each unit meet. Huddle conversations cover the needs of each unit for staffing and the availability of beds on that unit. Huddles provide a way to plan for known admissions and discharges. They also provide a forum to update about the available bed capacity on each unit, including the emergency department.
• Discharging patients sooner. The inpatient units aim to discharge patients by 11 a.m. As patients are medically ready to be discharged, the vacated beds can be targeted for a possible influx of emergency department patients. Said Shellenberger, “this is a multidisciplinary approach that involves nurses, physicians and many support services within the hospital.”
• Identifying areas of the hospital such as the Joint Replacement Center and Medical Day Stay Unit that can be used as overflow areas in case there is an influx of patients.

As the new policy is implemented, emergency department staff and physicians are increasing the frequency of care rounds, or check-ins with patients, to ensure the needs of patients are being met.

The comprehensive plan also includes a construction project that began in December that will add five new beds to the existing Emergency Department. The expansion will occupy adjacent space that formerly housed the operating rooms. Construction should be completed by April 2009.

Other investments in the emergency department include adding seven new Emergency Department physicians. A patient-satisfaction program has focused on reducing the average door to-door-time — the time from when a patient walks in the door to the time they leave the ED — from four hours to three hours. Last year, more than 37,000 patients were treated in Cooley Dickinson Hospital’s Emergency Department.